THE UNIVERSITY OF QUEENSLAND

Faculty of Medicine & Biomedical Sciences (M+BS)

School of Biomedical Sciences (SBMS)
Anatomy & Developmental Biology
2015

MEDI7112 Anatomy Practical Session

Clinical Science 2 (Week 2)

Anatomy of Mouth to
Stomach
Prepared by Dr Peter Wragg
in collaboration with Dr Vaughan Kippers & Dr Yacoob Omar
(Updated Tuesday, 30th June, 2015)
There are a couple of ways in which you may find it useful to use these
notes:
(a) Use them for your pre-lab prep, then perhaps prepare a checklist
of the things YOU want to clarify and identify in the lab
(b) For those whose preferred learning methods dont involve pre-lab
prep, bring the notes to the lab and work through them, preferably
in a group, and using your resources as well as the specimens to
work through the sections of the notes learning as you go.

Outline of this session:

In todays prac, we will be looking at the details of the mouth, including the
skeleton (maxilla, mandible, palatine bones), the tongue, salivary glands,
palate, & floor of the mouth. We will then revise the pharynx, and see how it
progresses down to become the oesophagus. We will look at the oesophagus
in the thorax, and its relations to structures such as the aorta, thoracic duct,
etc. We will then examine the oesophageal hiatus in the diaphragm in some
detail, including its clinical relevance, before concentrating on the stomach
itself. The stomach will be examined in detail, including its parts, blood supply,
and innervation. We will end this weeks prac at the gastric outlet, the pylorus.
Reading: Morton et al p240-244, 258-269, 294-299, 70/1, 98/9, 102/3, 108/9
Hankin et al p80-87

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

1. What do I REALLY need to know?

Face, Mouth, and Mandible

To start this prac, find a specimen or model of a skull, and revise/study the
following points.

On your specimens, identify the following bones, and note whether they
are single or paired:
o Zygoma (zygomatic bone)
o Maxilla.

On the maxilla, note the two processes frontal and zygomatic

which join with the bones of those names.

Note also that the maxilla has a palatine process that extends
horizontally to meet its fellow of the opposite side, to form the
greater part of the skeleton of the hard palate.

The alveolar process is actually the rim of the maxilla that

carries the teeth of the upper jaw

Note that the main body of the maxilla is hollow the maxillary
sinus.

Note also the infraorbital foramen just below the orbital rim this
carries the infraorbital nerve and artery.

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Now turn your skulls over, so youre looking from below and behind. Note
that the bony palate consists of the palatine processes of the maxillae, as
seen above, but that posteriorly, and adjoining these, are the two
horizontal plates of the palatine bones. These meet in the midline, as
well as joining with the palatine processes of the maxillae, and it is these
four components that together make up the skeleton of the hard palate.

Finally, check the mandible that you should have with your specimen/
model. Identify the following parts and features:
o Body of the mandible.
o Ramus of the mandible.
o Angle of the mandible.
o Mandibular notch.
o Condylar process, including the head and neck of the mandible.
o Coronoid process.
o Mandibular foramen on the medial aspect (the inside) of the
ramus, guarded by a small tongue of bone, the lingula of the
mandible.
o The mylohyoid line a roughened, slightly raised ridge on the
inside of the body of the mandible. The mylohyoid the main
muscle of the floor of the mouth attaches here.
o The alveolar margin of the mandible the part that carries the
teeth of the lower jaw.
o See if your specimen has a mental foramen, and/or a visible
mental symphysis.

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Teeth

Each tooth is composed of specialized connective tissue, the pulp,

covered by three calcified tissues: dentine, enamel, and cementum.
They are embedded in the alveolar processes of the maxilla and mandible,
and surrounded by the gums known as the gingivae.

There are 20 primary teeth in a child, and 32 secondary, or permanent,

teeth in an adult.

The teeth are divided into 4 quadrants, with 8 teeth in each in the adult:
o 2 incisors.
o 1 canine.
o 2 premolars.
o 3 molars. Note that the 3rd molar may erupt or not, and is known as the
wisdom tooth for reasons unknown.

The nerve supply and blood supply of the teeth is well described in
Morton et al p262/3. Some of the terms may be unfamiliar to you, eg
cranial nerves, as you havent studied neuroanatomy yet, but it is worth a
preliminary read of the innervation, and make a note to come back to it
once you have done the neuroanatomy module.

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Hyoid, Muscles of Mastication, and Tongue

The hyoid is a bone that does not articulate with any other bone directly. It
sits suspended from the styloid process of the skull by ligaments, lies in
the front of the neck between the mandible and the larynx at the level of
C3 vertebra approximately. It is the bone frequently fractured in cases of
choking or strangulation (but not always the murder-mystery books imply
that if the hyoid isnt fractured, then choking or strangulation could not
have occurred. This is not the case).

The hyoid has a central body, and from this a pair of greater horns and a
pair of lesser horns projects. Another name for a horn is cornu. So you
will see the terms greater and lesser cornu as an alternative to horn.

The hyoid has several muscles attached to it, from above, behind, and
below. These are involved in the functions of the tongue, floor of the
mouth, and pharynx. There are also muscles that lie anteriorly in the neck,
in front of the thyroid gland and the larynx, known as the strap muscles
that attach to the hyoid (except for the sternothyroid).

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Next group is the facial muscles, and while they seem to be a complex set
of muscles that are responsible for the entire expressive appearance of
our faces, the main ones you need to learn for this prac is the group of
muscles around the mouth the orbicularis oris. (The name means
around the mouth). This acts as the sphincter of the mouth, controlling
the opening and closure of the lips. One other you should know is the
cheek muscle, the buccinator (pronounced buxinator). This is
responsible for keeping food between the teeth while chewing, among
other things.

Next, we have the muscles of mastication chewing. These move the

mandible. Using your atlases etc, find and identify the following:
o Temporalis.
o Masseter.
o Lateral pterygoid.
o Medial pterygoid. Note how the two pterygoid muscles interleave at
their attachments to the pterygoid process, and note that the lateral
pterygoid attaches to the head and neck of the mandible to pull it
forward, while the medial pterygoid attaches to the medial surface of
the angle of the mandible much lower down, and hence acts to elevate
the mandible.

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

The muscles of the mouth and tongue include the tongue itself, which has
intrinsic muscles, and the extrinsic muscles that attach the tongue to the
mandible, hyoid, palate, and styloid process. The intrinsic muscles change
the shape of the tongue, while the extrinsic muscles change the position of
the tongue. The main ones you need to know are the extrinsic muscles,
including the genioglossus, the hyoglossus, the styloglossus, and the
palatoglossus. If you know that the glossus bit refers to the tongue
(glossi = Greek; lingua = Latin), then you can work out which muscle
comes from where. The genial tubercles are the little bumps on the inside
of the anterior part of the body of the mandible, so the genioglossus runs
from there to the tongue. Im sure you can work out for yourselves where
the other three named above are attached at the end other than the
tongue attachment!

Other muscles of the mouth include those associated with the soft palate,
the pharynx, the cheek (eg the buccinator seen above), and the muscle
forming the floor of the mouth, the mylohyoid, which is also included in
the hyoid group of muscles.

Using your atlases and specimens, check as many as possible of the

muscles that are attached to the hyoid, including:
o Mylohyoid forms the floor of the mouth
o Stylohyoid from the styloid process of the temporal bone
o Hyoglossus (upwards to the tongue - seen above)

MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

o Geniohyoid attaches the hyoid to the genioid tubercles
o Digastric (means two bellies) check anterior and posterior bellies
o Omohyoid from the scapula, via a fascial sling on the manubrium
and clavicle
o Middle constrictor of the pharynx.
o Sternohyoid one of the infrahyoid muscles, from the back of the
manubrium
o Thyrohyoid another infrahyoid muscle, from the thyroid cartilage of
the larynx. The infrahyoid muscles are known as the strap muscles,
and also include the sternothyroid.

Pharynx

Revise the pharynx from your Upper Respiratory Tract in MEDI7111

(Week 11).

The pharynx consists of a muscular tube suspended from the base of

the skull, comprising three circular muscles stacked like three plant pots
into one another the constrictors. They are all open anteriorly, so theyre
not complete circular muscles. Using your atlases to help, try to identify on
a specimen or model the superior, middle, and inferior constrictor.
Note where they attach anteriorly on either side of their openings.

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There are also three vertical muscles forming part of the pharynx see if
you can find them: the stylopharyngeus, palatopharyngeus, and
salpingopharyngeus (from the auditory tube).

The nerve supply to the pharynx is from the vagus and glossopharyngeal
nerves (cranial nerves X and IX respectively), which form the pharyngeal
plexus.

Salivary Glands

The parotid gland is a salivary gland that occupies the space between the
mastoid process and external acoustic meatus behind, and the ramus of
the mandible in front. It is wrapped around the posterior edge of the ramus
of the mandible. It is divided into two nominal parts (superficial and deep)
by the facial nerve. The parotid duct runs forward from the superficial part
of the gland to pierce the buccinator and enter the oral cavity adjacent to
the upper 2nd molar tooth. The gland has a tough fibrous pseudocapsule,
and this is one of the reasons that swelling of the gland, trying to stretch
this capsule, can be so painful eg. in mumps.

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The submandibular salivary gland lies in the submandibular region, and

is folded over the posterior edge of the mylohyoid muscle, thus forming
deep and superficial parts. The gland is closely related to the facial artery
and vein (check in your atlases and on specimens), and the deep part of
the gland lies lateral to (i.e. outside) the hyoglossus muscle. Other
structures in this region to note include the lingual nerve, the hypoglossal
nerve, and the submandibular duct running forward from the gland itself
to enter the mouth just beside the frenulum of the tongue (the median fold
that tethers the tongue to the floor of the mouth).

The sublingual gland lies above the mylohyoid, just beneath the mucous
membrane of the floor of the mouth. It is the smallest of the three paired
salivary glands, and opens into the mouth via multiple small ducts, directly
into the floor of the mouth.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Oesophagus

The oesophagus is the downward continuation of the pharynx, and the

upper 20% of the oesophagus lies in the neck. The total length of the
oesophagus is between 25 & 30cm, depending on the size of the person.

It starts behind the cricoid cartilage of the larynx, and the encircling muscle
fibres here are known as the cricopharyngeus muscle. It is actually the
lowermost fibres of the inferior constrictor of the pharynx, and these act as
a sphincter at the top of the oesophagus. They are skeletal muscle.

Just above the cricopharyngeus, between it and the rest of the inferior
constrictor proper, is a relatively weak spot, (Killians area) and it is here
that you may see a diverticulum (a blow-out or outpouching) called a
Zenkers diverticulum, otherwise known as a pharyngeal pouch.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

The oesophagus has an inner circular muscle layer, and an outer

longitudinal muscle layer, starting just below the cricopharyngeus muscle.
One interesting fact about the musculature of the oesophagus is that it is
skeletal muscle at the top, and smooth muscle at the lower end, with a
gradual transition from one type to the other.

The oesophagus descends into the thorax behind the trachea, and is
closely related to the very thin, soft, posterior wall of the trachea. Below
the tracheal bifurcation, the oesophagus is closely applied to the
back of the left atrium of the heart. This is where the transducer is
placed during a procedure called a transoesophageal echocardiogram,
so that the ultrasonic view of the heart from behind is only looking through
one wall of the oesophagus and the thin wall of the left atrium.

As the oesophagus descends through the posterior mediastinum, the

descending aorta swings in behind it, so that the oesophagus is in front
of the aorta. See following diagram, and also See diagram on page 71 of
Morton et al.

The blood supply of the oesophagus is from several small arteries

branches of the inferior thyroid arteries in the root of the neck, branches
from the bronchial arteries in the chest, and usually one or two direct
oesophageal branches from the descending aorta in the thorax. Also a
branch of the left gastric artery supplies the lower oesophagus.

Recall that an anastomosis of the VEINS of the lower oesophagus with the
left gastric vein is one of the important porto-systemic anastomoses,
relevant in portal hypertension, when oesophageal varices can grow
enormous and bleed profusely.

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The left and right vagus nerves approach the oesophagus from each side,
and form a plexus on the surface of the oesophagus. At the level of the
diaphragm, the plexus eventually merges into two vagal trunks. (See
diagram on page 14 above).
o The left vagus becomes the anterior vagal trunk as it passes through
the diaphragm
o The right vagus becomes the posterior vagal trunk.
o If you recall from your Embryology lecture how the stomach rotates,
you will understand how the left vagus becomes anterior, and the right
becomes posterior.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

The oesophagus passes through the diaphragm at about the level of

thoracic vertebra 10 (T10). This aperture is the oesophageal hiatus, and
is formed by looping fibres that arise from the RIGHT crus of the
diaphragm, even though the hiatus itself is just to the LEFT of the midline.

The junction of the oesophagus with the stomach is known as the gastrooesophageal (or oesophago-gastric) junction, but also by the much shorter
name of the cardia.

There is no TRUE sphincteric muscle here in the oesophagus itself, but

the looping fibres of the right crus of the diaphragm that form the
oesophageal hiatus act as a physiological/functional sphincter to prevent
gastro-oesophageal reflux.

When this hiatus is too loose, the stomach can either slide up through the
hiatus (a sliding hiatus hernia) or the fundus of the stomach can roll up
beside the oesophagus a para-oesophageal hiatus hernia. This latter
type is potentially very dangerous, while the sliding type is more of a
nuisance and can be very symptomatic due to the reflux.

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Stomach

Note that the adjective gastric refers to the stomach, specifically. It is

NOT as commonly used by many members of the public - a term used to
describe diarrhoea (!)

Note the general position of the stomach, and how it can vary in size and
shape quite significantly from one specimen to another.

Using your texts, atlases, and other resources, and using the specimens
and/or models, identify the following parts of the stomach:
o Fundus.
o Body.
o Antrum and pylorus feel the pylorus and note how much thicker it is
than the stomach before it and the duodenum following it.
o Greater and lesser curvatures.
o Note that an empty stomach tends to keep much the same overall
shape, but it flattens from front to back (that is, antero-posteriorly).
When full, it assumes a much more globular shape, and there is
usually a gas bubble of varying size in the fundus (when in the upright
position).

Examine an opened stomach, and note the numerous folds in the gastric
mucosa these are called rugae.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

Look for the cardiac orifice (in this context, the adjective cardiac does
NOT refer to the heart it refers to the cardia, the opening into the
stomach of the oesophagus). This is also called the oesophago-gastric
junction.

Try and find the pyloric sphincter, and if it has been cut through on your
specimen, note just how thick that circular muscle is. If it has not been cut
through, try to push your fingertip through it and note how tight it can be.

Note the four main arteries supplying the stomach:

o Left gastric artery, from the coeliac trunk, supplying mainly the lesser
curvature from the upper part heading down and to the right. This joins
with the right gastric artery, usually from the common hepatic artery,
heading back around the lesser curve from right to left. This forms an
arterial arc running around the lesser curve, with branches running
from it onto the stomach.
o In a very similar way, there are two gastroepiploic arteries (epiploic
refers to omentum) that form an arc running around the greater
curvature. The left gastroepiploic artery arises from the splenic artery
near or in the hilum of the spleen, and runs down and around to the
right where it joins the right gastroepiploic artery that arises from the
gastroduodenal artery.
o In addition to these four main arteries, there are some smaller arteries
that arise from the splenic artery near the hilum of the spleen, and run
towards the right to supply mainly the fundus of the stomach. These
are the short gastric arteries.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

If you have access to a specimen with an intact lesser omentum, note

where it attaches to the stomach, and to the liver (this is also known as the
gastrohepatic ligament).

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

While the greater omentum is essentially continuous around the greater

curvature of the stomach, note that if you follow it round and up towards
the fundus, it attaches to the spleen this is the gastrosplenic ligament
(its really just a part of the greater omentum). Recall from the video you
saw in the Embryology lecture that this whole structure forms from the
dorsal mesogastrium, with the spleen forming within the dorsal
mesogastrium. The rest of the dorsal mesogastrium, between the spleen
and the left kidney and diaphragm, is the lienorenal ligament (also known
as the spleno-renal ligament. Lieno (pronounced lye-eeno) refers to
the spleen).

After watching the video linked below, you should understand that surgical
entry into the lesser sac is via the gastrocolic ligament, and the following
picture shows this part of the greater omentum cut through, and the
stomach reflected upwards to reveal the posterior abdominal wall
structures, such as the pancreas.

For those who would like to watch the 4-minute video again, on the
development of the foregut and the mesogastria, here is the link:

https://www.youtube.com/watch?v=s2cNCUL1r3A

Note that there are two or three versions of this video on YouTube,
including one with background music(!) The version I have linked to here
is the one with the better audio.

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

From that video, remind yourself of the derivatives of the:

o ventral mesogastrium (lesser omentum, liver with its coronary and
triangular ligaments, falciform ligament) and
o dorsal mesogastrium (greater omentum, spleen, spleno-renal ligament,
etc).

Also, remind yourself why there is a free edge of the lesser omentum (its
where the ventral mesogastrium finishes, at the junction of foregut and
midgut), and how the lesser sac forms. The lesser sac, you will recall, lies
behind the stomach, and in front of the pancreas.

In the free edge of the lesser omentum, the portal vein (posteriorly) and
the bile duct and hepatic artery can be found. Now look for an opening that
has these three structures in front, and the IVC, liver, right suprarenal
gland, and perhaps the upper pole of the right kidney behind. This is the
opening into the lesser sac of the peritoneal cavity known as the
epiploic foramen (also widely known by its eponym of the foramen of
Winslow), indicated by the little arrow just to the right of the red dot in the
following picture. Also seen in the picture on p19 above.

In cases of severe bleeding from the liver, during abdominal surgery, there
is a manoeuvre whereby a finger is placed through the epiploic foramen,
and the structures in the free edge of the lesser omentum (portal vein,
hepatic artery, and bile duct) are grasped between the thumb in front and
the finger behind. This can control the bleeding significantly, and is known
as the Pringle Manoeuvre. It is used to gain control of massive
haemorrhage until a more definitive strategy can be applied, eg direct
oversewing of a liver laceration, or even just a proper clamp to replace the
fingers performing the manoeuvre, etc.
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In the following diagram, on the left is the Pringle Manoeuvre while on the
right is a clamp replacing the finger and thumb.

In the next diagram, the Pringle Manoeuvre is being used to guide a clamp
that has been inserted through an opening in the lesser omentum:

Lymphatic drainage

The stomach lymphatic drainage tends to follow its arterial supply back, as
is the case generally. So a cancer of the stomach can spread to nodes in
the spleen, the pancreas, greater omentum, and to the para-aortic nodes.

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There is a collection system for the lymphatic drainage of the stomach and
upper small intestine, lying just below the diaphragm, called the cisterna
chyli. It is named this because the fatty substances absorbed from the
upper bowel form a milky-white oily fluid called chyle. This accumulates in
the cisterna chyli and then the thoracic duct drains upwards from this
structure, to end in the major veins at the root of the neck, draining back
into the venous circulation at that point. Thus, lymph and chyle together
empty back into the venous circulation eventually. So it is not hard to
imagine how malignancies of the upper GI tract particularly the stomach
can spread to the root of the neck and subsequently back into the
venous system, and thence to anywhere.

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2. What would be useful to know in addition to the above?

In relation to the soft palate, examine a skull from below, and imagine how
the soft palate hangs from the back of the bony hard palate. The control
of the soft palate is vital for coordinated swallowing, the gag reflex, and
speech. So how is this controlled? The soft palate consists of a sheet of
fibrous aponeurosis with muscles inserted into it, and hence can be
tensed and elevated. A muscle called tensor palati arises from the fossa
between the pterygoid plates, and has a tendon that hooks around the
pterygoid hamulus on the medial pterygoid plate, and enters the soft
palate from the side. It thus pulls sideways against its opposite number,
tensing the soft palate. Another muscle, the levator palati, arises from the
inferior surface of the petrous temporal bone and the cartilaginous part of
the auditory tube, and inserts into the palatine aponeurosis. As this muscle
is pulling from more posteriorly, it elevates the free edge of the palate, as
opposed to tensing it. There are two other muscles involved with this
small structure, the soft palate the palatoglossus, and the
palatopharyngeus. These run downwards from the lateral part of the soft
palate, forming two arches on the side wall of the pharynx near the back
of the tongue. It is between these two folds that the palatine tonsils lie
these are masses of lymphoid tissue, and generally called simply the
tonsils. But the muscles that make up the two arches are also active in
closing off the oral cavity from the pharynx (by moving together with the
corresponding muscles on the opposite side) and moving the soft palate
down like a trapdoor.
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You can see from the above descriptions (which, believe it or not, are
simplified) that the control and function of the soft palate is vital. And due
to the complexity of its operation, it is one of the control mechanisms that
fails in conditions such as stroke, for example.

Now look at the tongue and its muscles. As mentioned earlier, the intrinsic
muscles change the SHAPE of the tongue, while the extrinsic muscles
change the POSITION of the tongue. And all of these except the
palatoglossus are innervated by the hypoglossal nerve (cranial nerve XII).
Identify on a specimen or model the genioglossus. Note that it is attached
anteriorly, to the genial tubercles on the posterior surface of the mental
process of the mandible (the chin). So, given that it fans backwards and
upwards into the tongue, what is its action if it contracts?

The answer to that, of course, is that it protrudes the tongue. Now, if a

patient has a lesion of the hypoglossal nerve, so that the muscles of the
tongue on one side are paralysed, and if you ask that patient to poke out
their tongue which way would you expect the tongue to deviate?
Towards the side of the lesion, or away from it? Think of the anatomy of
the genioglossus to work out the answer.

Note from the following picture that the intrinsic muscles are in 3
dimensions longitudinal, transverse, and vertical.

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And just as a reminder, here are the extrinsic muscles again but you
should be familiar with these by now ;)

And finally, a summary of the tongue muscles and their actions,

innervation etc:

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

The nerve supply of the oesophagus is worth mentioning, particularly as

the muscular coat of the oesophagus (inner circular and outer longitudinal)
is skeletal muscle in the upper third (so-called voluntary muscle), smooth
muscle in the lower third, and mixed in the middle third. It forms a gradual
transition from top to bottom. So the nerve supply is interesting.

Special motor fibres in the vagus supply the skeletal muscle in the
upper oesophagus. Parasympathetic preganglionic fibres also from the
vagus enter the smooth muscle in the lower part, with these fibres
synapsing in the wall of the oesophagus with very short postganglionic
fibres then supplying the smooth muscle.

It is worth remembering that the vagus is not JUST a parasympathetic

nerve, although that is its major function. It supplies skeletal muscle
(oesophagus, and you will recall that it also supplies most of the skeletal
muscle of the pharynx, and larynx too). This is an example of so-called
voluntary skeletal muscle acting in an involuntary way, innervated by the
vagus although swallowing, speech etc can be initiated voluntarily, the
actual muscle functions are largely autonomous once initiated. It is hard to
stop a swallow once it is under way.

There is also sympathetic innervation of the oesophagus, both directly

from the sympathetic trunk and via branches from the splanchnic nerves
(all as postganglionic fibres). These are thought to act contrary to the
parasympathetic fibres, causing relaxation of the oesophagus to allow
bolus passage. Pain from the oesophagus is also mediated via these
sympathetic connections back to the sympathetic trunks. This is the pain
that is commonly referred to as heartburn as it is burning in nature and
situated just behind the lower sternum, and is usually caused by acid
reflux from the stomach. Heres a summary of autonomic supply to the GIT

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The stomach has a strong muscular layer arranged chiefly into an inner
circular and outer longitudinal layer, although there are spiral oblique
fibres interspersed with these, particularly towards the inner part of the
stomach wall. Some books describe a definite innermost oblique layer,
while others have the oblique fibres throughout the wall as described
above, but with a predominance towards the inner (luminal) part of the
wall. These layers ensure that the stomach is capable of churning and
grinding food and ensuring good mixing, especially as it gets softened by
gastric enzymes.

The mucosa of the empty stomach is thrown into folds called rugae, which
generally run longitudinally. However, these folds are not permanent
they are dynamically changing as the stomach changes its shape, due
both to filling and also to the contractions of the muscle layers.

Solid food can remain semisolid or solid for several hours, before slowly
becoming a smooth liquid mixture called chyme. The pylorus allows
passage of liquid, but solids are retained in the stomach until digested
more. Interestingly, different foods are emptied into the duodenum at
different rates. Carbohydrates are the first to be emptied (after an hour or
two), proteins are next, and fats are the slowest.

The lymphatic drainage of the stomach is important, as gastric tumours

can occur in different parts of the stomach. The routes of drainage are
important for the treating medical team to understand. They eventually
drain into the cisterna chyli as described in Section 1 of these notes, and
thence to the thoracic duct. But there are regional groups of nodes around
the stomach, as shown in the following diagram:

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MEDI7112 Anatomy Prac Anatomy of Mouth to Stomach

3. WHY do I need to know this?

You will be seeing patients who have cancer of the stomach and you need
to understand the anatomy of the condition itself eg where is it likely to
spread via either the lymph nodes or via the venous return but also the
anatomy of the surgery that may need to be performed.

You will be seeing some of this anatomy from the INSIDE in your clinical
rotations you will see endoscopies performed, looking down into the
stomach and duodenum.

The various developmental anomalies mentioned earlier in these notes

and in the lectures, such as trachea-oesophageal fistula or oesophageal
atresia are particular problems in infants, and unless treated, can be
incompatible with life.

Hiatus hernia is a very common problem but we dont really know why is
it diet-related? Obesity? Is there any geographical difference in the
incidence? (something for you to research). But it is important that you
know the anatomy of the condition, and also to understand why a sliding
hiatus hernia can be very symptomatic but rarely acutely dangerous,
whereas a rolling (para-oesophageal) hiatus hernia has the potential for
very acute life-threatening complications.

Cancer of the oesophagus is an awful condition, related to smoking (but

also occurring in non-smokers). The oesophagus is lined by nonkeratinising squamous epithelium, so tumours of the main part of the
oesophagus tend to be squamous cell carcinomas. Tumours close to the
oesophago-gastric junction (the cardia) tend to involve the glandular
gastric-type epithelium and therefore are more commonly
adenocarcinomas. Treatment of oesophageal cancer is an area that can
be particularly demanding, and depending on the stage at which the
tumour is diagnosed, the results of treatment can range from very good to
very poor. Complications of treatment are common, whether the treatment
is surgical, or chemo-radiation, or both. But the anatomy of the
oesophagus and the applied anatomy of the surgical options to treat this
devastating condition is obviously very important.

Problems involving the mouth are everyday common problems that are
seen by GPs, emergency doctors, dentists, pharmacists, nurses, and a
whole range of other specialties. These problems can range from fungal
infections (Candidiasis, for example) that can severely impact on the ability
to eat properly, problems with the teeth, problems with the tongue, palate,
pharynx (eg pharyngeal pouch), all the way through to major malignant
tumours involving the mandible, maxilla, tongue, lips, or even half the face.
These can be a real challenge in terms of being able to work with the
anatomy to provide airway, ability to drink and eat, and drain salivary
secretions.

We will see more potential problems when we study the rest of the GIT.

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